Provider Demographics
NPI:1740343094
Name:GRACE, PETER MATTHEW (DC)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:MATTHEW
Last Name:GRACE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 VERSAILLES RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-3207
Mailing Address - Country:US
Mailing Address - Phone:502-695-4455
Mailing Address - Fax:502-695-0727
Practice Address - Street 1:160 VERSAILLES RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-3207
Practice Address - Country:US
Practice Address - Phone:502-695-4455
Practice Address - Fax:502-695-0727
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4715111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50004093Medicaid
KY000000292695OtherANTHEM
KY50004093Medicaid
U74767Medicare UPIN